Double Standards

Psychiatrist Duncan Double was once suspended from his NHS trust for “deficient” practice. In a new book which he co-edits Double argues the suspension was political, largely because he practiced “critical psychiatry”, an approach refuting the biomedical understanding of mental illness. The book lays out the foundations of critical psychiatry and its contributors include the most influential names in this field. In an interview with Adam James, Double talks candidly about his suspension and argues it is time traditional psychiatry stopped seeing psychiatrists such as himself as a “threat”.

If you or I were so distressed to be referred to a psychiatrist, he or she is unlikely to assist you in the way of Duncan Double, one of a handful of vocal “critical” psychiatrists working in the NHS.

Sceptical of the medical and scientific validity of psychiatric diagnoses and benefits of psychiatric drugs, such psychiatrists understand their patients from, they argue, a perspective which is more humane and less stigmatising. So, for example, they are less inclined to diagnose schizophrenia for a patient hearing abusive voices and prescribe anti-psychotics. Instead, they might try to help that person understand what their voices represent, and work out ways to help them control such voices.These men and women have, in effect, taken over the baton of “anti-psychiatry”, famously represented by the thinking during the sixties and seventies of psychiatrists and writers Ronald Laing, Thomas Szasz and David Cooper.

But – as Double learnt – opposing the traditional biomedical thinking on the nature of mental illness, can carry severe consequences. Despite being a consultant psychiatrist and honorary senior lecturer at the University of East Anglia’s medical school, Double was suspended in 2001 for six month from his NHS job. It followed GPs raising concerns over how Double was working with suicidal patients. Double says his employers told him his practice was “deficient” and “unsafe”, that he needed re-training in “organic psychiatry” and that he must undergo clinical supervision for one year. Double says he was told that if he did not agree he would be disciplined.

For Double, the stress brought on by the suspension was “absolutely horrendous” – for him and his family. Yet, with five years to reflect, Double is adamant that his suspension – which was supported by his professional body the Royal College of Psychiatrists – was political. Double says that psychiatrists like him are seen as a “threat” by the biomedical hegemony gripping contemporary psychiatric practice.

Moreover, Double believes that colleague distrust – and outright anger – towards him was enflamed by two factors. First, Double had launched an “antipsychiatry” website documenting the approach of critical psychiatry, and secondly, he was the psychiatrist of Kay Sheldon who, in February 2001, received an out-of-court settlement of £58,000 from Norfolk Health Authority after she claimed she was wrongly diagnosed and treated [by a previous psychiatrist] for schizophrenia over a 15 year period. Moreover, Double says that the slurs made against his practice were never formally investigated. “Basically I was regarded as different,” Double said. “I was using less medication than many psychiatrists and was not so concerned about arriving at diagnoses. In the end the person who the Royal College of Psychiatrists referred me to for retraining in organic psychiatry refused to do it because, he said, the whole matter was political.”

Debates about the aetiology of mental illness have raged within psychiatry and academia ever since psychiatry endeavoured to carve itself out as a medical discipline in the 17th century. The term “critical psychiatry” was coined in 1980 by David Ingleby, professor of intercultural psychology at Utrecht University in the Netherlands. And what critical psychiatry shares with anti-psychiatry is its refute that the mentally “ill” have an intrinsic brain disorder and that physical intervention is of highest clinical importance. Instead, critical psychiatry – similar to Laingian existential psychology – attempts to understand (and treat) severe distress within the “psycho-social” context of a person’s experience.

Within academia, rigorous debate over such philosophy-of-mind concerns and implications for practice is both expected and encouraged. Within actual psychiatric practice, however, such critical views can be demonised, says Double. In fact, this was something Double learnt early on in his career. When a trainee psychiatrist in Cambridge he attended seminars to discuss journal articles. During one seminar he questioned the traditional medical understanding of mental illness. “I remember my psychiatry tutor saying to me ‘this is dangerous talk’,” remembers Double. “Yet all I was doing was trying to work out how we should be psychiatrists.”

Such an austere rebuff to intellectual enquiry can be contrasted to Double’s “liberating” years from 1989-92, when he was a lecturer in psychiatry at the University of Sheffield. At that time, the department of psychiatry was headed by Prof Alec Jenner, co-founder of the voluntarily-run radical mental health magazine Asylum (which this year celebrated its 20th anniversary). “Jenner was in tune with my views, and there was nowhere else in the country that I could have gone,” says Double.

Nevertheless, despite such a positive experience of academia, Double chose to combine it with continuing a practitioner path. “If critical psychiatry means anything it should be involved in practice,” he stresses. And, in what some might see as an intellectual riposte to the questioning of his practice incurred by his suspension, Double is co-editor of a new book, Critical Psychiatry; Limits of Madness. It traces the philosophical, scientific and historical foundations of critical psychiatry, and Double contributes three chapters. The other nine are by some of the leading thinkers and practitioners in both critical psychiatry and psychology. They include a chapter by Lucy Johnstone, academic director of clinical psychology at the University of Bristol, who argues that acts of making psychiatric diagnoses are social judgement lacking medical objectivity. In a strikingly similar experience to Double, Johnstone says her dissenting views on psychiatric practice led to her once being hounded out of clinical NHS work. Another chapter by psychiatrist Joanna Moncrieff, senior lecturer in social and community psychiatry at University College, London, critiques the evidence base for psychiatric drugs; and Phil Thomas, senior research fellow at the centre for citizenship and community mental health, University of Bradford, co-writes a chapter arguing that, under postmodernist scrutiny, psychiatry’s modernist foundations are untenable.

Importantly, Critical Psychiatry draws out how critical psychiatry is distinct from anti-psychiatry which, Double argues, eventually became preoccupied with exploring existential paths to personal enlightenment rather than pressing for progressive psychiatric practice. Moreover, Double says that – unlike anti-psychiatry – critical psychiatry is willing to engage meaningfully in scientific debate over the validity of psychiatry’s biomedical evidence base. “Critical psychiatry engages with the data” is how Double puts it. “I do see myself as a scientist, and I so see my approach as scientific – not just in an empirical sense, but a broad sense of making enquiries.”

Moncrieff’s chapter – entitled The Politics of Psychiatric Drug Treatment – characterises this “broad” enquiry. It examines how the billion pound pharmaceutical industry has formed an alliance with a prestige-yearning psychiatric profession and successive British governments eager to “transform social and legal problems [of the mentally ill] into scientific and technical ones”. One consequence, argues Moncrieff, has been the consistent overplaying of the benefits of psychiatric drugs. After examining the data on drug efficacy, Moncrieff concludes: “The psychiatric community appears to have lost the ability to imagine that life with serious mental illness is possible, and maybe sometimes better, without [psychiatric] drugs.”

Double decided to document his suspension in Critical Psychiatry in a bid to convince mainstream psychiatry that it should not judge psychiatrists like him as a “threat”. He tells readers: “The aim is that by the end of the book you will be able to decide for yourself whether critical psychiatry is really such a threat. In my view, the book will have succeeded it it makes plain the self-deception, albeit unconscious, of much of biomedical psychiatry, and encourages instead a more open mental health practice.”

Surely now – as head of a multi-disciplinary community mental health team in Norwich, a wealth of journal articles and a co-edited book to his name – Double should have no fear that the validity of his practice will again be put under the spotlight? Alas, not so. Double remarks: “If there were power struggles again [within the trust] it would be an easy thing to open up again.” Being critical comes at a price.

* Critical Psychiatry; Limits of Madness is published in hardback on May 19, priced £50, by Palgrave Macmillan (0230001289) 
* Critical Psychiatry Network: www.critpsynet.freeuk.com

A shortened version of this article was published by the Times Higher Education Supplement

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