'My tutor said to me, this talk is dangerous'

Reprinted from Times Higher Educational Supplement, April 21, 2006

Since his student days, psychiatrist Duncan Double has sought to take the stigma out of mental illness. But his controversial methods led to his suspension in October 2000, reports Adam James.

Duncan Double is one of a handful of "critical" psychiatrists working in the National Health Service. Such psychiatrists are sceptical of the medical and scientific validity of psychiatric diagnoses and the benefits of psychiatric drugs. They argue that they understand patients from a more humane and less stigmatising perspective. So, for example, they are less inclined to diagnose schizophrenia in a patient hearing abusive voices and to prescribe anti-psychotic drugs. Instead, they might try to help that person understand what the voices represent and work out how to control them.

Double's work has not been without controversy. Despite being a consultant psychiatrist and honorary senior lecturer at the University of East Anglia's Medical School, he was suspended by his NHS trust in 2000 for six months after GPs raised concerns about his work with suicidal patients.

Double was told that his practice was a clinical risk and says he was advised to undergo retraining in "organic psychiatry" and to submit to clinical supervision following a confidential recommendation by the Royal College of Psychiatrists. Double says his college assessors indicated that if he did not agree, his philosophy on psychiatry would need to be examined and his scepticism about the use of medication challenged.

He adds that the stress brought on by the suspension was "absolutely horrendous" for him and his family. Double believes that psychiatrists like him are seen as a threat by the biomedical hegemony gripping contemporary psychiatric practice. Moreover, he thinks that his colleagues' distrust of him was exacerbated by an "anti-psychiatry" website he launched to document the approach of critical psychiatry. "Basically, I was regarded as different," Double claims. "I was using less medication than many psychiatrists and was not so concerned about arriving at diagnoses."

Debates about the aetiology of mental illness have raged in psychiatry and academia ever since modern psychiatry tried to carve itself out as a medical discipline in the 19th century. The term "critical psychiatry" was coined in 1980 by David Ingleby, professor of intercultural psychology at Utrecht University in the Netherlands. It takes up the baton of "anti-psychiatry", represented by psychiatrists and writers of the Sixties and Seventies, such as Ronald Laing, Thomas Szasz and David Cooper.

Critical psychiatry shares with anti-psychiatry the belief that the mentally "ill" do not have an intrinsic brain disorder and that physical intervention is not vital. Critical psychiatry attempts to understand and treat severe distress in the "psychosocial" context of a person's experience. Within academia, rigorous debate over such issues is expected and encouraged. But in psychiatric practice, such views can be demonised, Double says. He learnt this early in his career. As a trainee psychiatrist based at Fulbourn Hospital, which is affiliated to Cambridge University, 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'," Double says. "Yet all I was doing was trying to work out how we should be psychiatrists."

However, between 1989 and 1992 as a lecturer in psychiatry at Sheffield University, he had the freedom to explore his views. At that time, the department of psychiatry was headed by Alec Jenner, co-founder of the radical mental health magazine Asylum. "Jenner was in tune with my views, and there was nowhere else in the country that I could have gone," Double says.

Nevertheless, Double chose to combine his academic work with continuing along a practitioner path. "If critical psychiatry means anything, it should be involved in practice," he stresses. And, in what some might see as a riposte to his suspension, he is editing a book, Critical Psychiatry: The Limits of Madness. It traces the philosophical, scientific and historical foundations of critical psychiatry, and Double contributes four chapters.

The other eight have been written by leading thinkers and practitioners in critical psychiatry and psychology. They include Lucy Johnstone, academic director of clinical psychology at Bristol University, who argues that psychiatric diagnoses are social judgments that lack medical objectivity. Johnstone has had a similar experience to Double's, in which she says her dissenting views on psychiatric practice led to her leaving clinical NHS work.

The book 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, he says that - unlike anti-psychiatry - critical psychiatry is willing to engage in meaningful debate over the validity of psychiatry's biomedical evidence base. "Critical psychiatry engages with the data", as Double puts it. "I do see myself as a scientist, and I do see my approach as scientific."

One chapter, by Joanna Moncrieff, senior lecturer in social and community mental health at University College London, typifies this "broad" approach. It critiques the evidence base for psychiatric drugs and claims that the billion-pound pharmaceutical industry has formed an alliance with a prestige-seeking psychiatric profession and successive British governments eager to "transform social and legal problems [of the mentally ill] into scientific and technical ones". One consequence, Moncrieff argues, has been the consistent overplaying of the benefits of psychiatric drugs. She 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 documented his suspension in Critical Psychiatry in an effort to convince mainstream psychiatry that it should not judge psychiatrists like him 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 if it makes plain the self-deception, albeit unconscious, of much of biomedical psychiatry, and encourages instead a more open mental health practice."

But surely now - as consultant lead of a multidisciplinary community mental health team in Norwich, with a wealth of journal articles and a book to his name - Double should feel confident that his practice will not be put under the spotlight again? Not so. Double remarks: "If there were power struggles [within the trust], it would be an easy thing to open up again."

Critical Psychiatry: The Limits of Madness was published by Palgrave Macmillan