The Site invited Dr. James Davies to give a talk at the October Gallery in May of this year. The talk, entitled ‘The DSM - a great work of fiction?’ was convened by The Site to mark the publication the following week of the DSM-V (Diagnostic and Statistical Manual of Mental Disorders). The title of the talk was taken from the heading of Chapter Two of his recently published book Cracked: Why Psychiatry Is Doing More Harm Than Good. This event was well attended by both Site members, trainees and other interested parties. Davies is a lucid and entertaining speaker and the talk provoked a lively discussion with the audience. His talk primarily focused on the DSM but his book goes considerably further than this. Davies is a psychotherapist who has worked in the NHS. His doctorate is in medical and social anthropology and he is a senior lecturer in social anthropology and psychotherapy at the University of Roehampton. His academic background gives him both the access and skills to research his project thoroughly. Thus, he has written a book that is aimed at the general reader and service user that nevertheless has much to offer to mental health professionals.
Davies sets out his stall in the preface:
“I will investigate three medical mysteries: why has psychiatry become the fastest-growing medical specialism when it has the poorest curative success? Why are psychiatric drugs now more widely prescribed than almost any other medical drugs in history, despite their dubious efficacy? And why does psychiatry, without solid scientific justification, keep expanding the number of mental disorders it believes to exist - from 106 in 1952 to 374 today? what is going on?”.
As you can probably already tell from that short extract, Cracked has a snappy journalistic style and not the style that is normally found in Sitegeist or other academic journals. Some may balk at this, calling it lightweight, as indeed some online reader reviews have done. At the Site talk, Davies said that he could have written an academic work which would have been read by a few but would not have reached the people who it most affects, the general public. Perhaps it can at times feel like the script of a caper movie as Davies jets around the world and there is a tendency to have a cliffhanger at the end of every chapter. I have no problem with this and in fact I welcome it because it gives a sense of his enthusiasm. I find it refreshing that Davies does not obfuscate his project with the language of the elite. Having said that, the book is extensively researched and footnoted for those who wish to explore the academic texts. Cracked investigates three “mysteries”, and it is these big and very important “mysteries” that Davies sets out to answer in the course of his investigation.
Davies' approach to his investigation combines classic research strategies of mega-analysis with those of the investigative journalist. The journalistic aspect is very enlightening because he was able to interview leading figures in the psychiatric world in the USA and in Britain. I suspect his academic credentials got him access to figures like Robert Spitzer, the father of DSM-III and the man who really put it on the map. It may also account for why Davies' interviewees were so candid with him.
What Davies discovers is a cozy cabal of project groups that come up with new disorders and then decide what symptoms constitute them. Spitzer in his interview is completely open about this and acknowledges there was nothing scientific about it. It would be easy to dismiss this as a problem for the USA as in Britain we use the ICD (International Statistical Classification of Diseases and Related Health Problems). Or do we? NICE
(National Institute for Clinical Excellence) prefers the DSM for its evidence base for treatments and IAPT (Improving Access to Psychological Therapies) even more so. There is an irony here as both IAPT and NICE, with their emphasis on ‘evidence based treatments’, favour CBT as their treatment of choice. However, CBT being diagnostic and symptom based cannot operate without the DSM diagnoses, which Davies illustrates has little or no scientific evidence to support it.
Of course, Davies is not the first to raise these concerns but they are more widespread than I had realised. A recent exchange with a retired GP confirmed this. She asked me what I was doing now that I had retired from the NHS. I told her that I had been doing some writing around the DSM-V and without pausing for breath she retorted, “Fiction!” However, she retired early from the NHS and before its almost pathological obsession with monitoring and data collection. Perhaps current GPs would be less sceptical. Davies is not claiming original research apart from the interviews which flesh out already published material. However, the interviews give an immediacy that research often does not convey. Bringing the evidence together in one book, perhaps for the first time, makes for a powerful challenge to the psychiatric orthodoxy.
In the latter half of the book, Davies moves on to examine the pharmaceutical industry and its claims for effectively being able to treat common mental health problems. It is very easy to take a stand against antidepressants on a philosophical basis and I'm sure that Davies would do this too but what he presents cogently is the woeful lack of evidence of their efficacy. However, he doesn't stop there: he goes on to show research that challenges some received notions about brain chemistry that have entered into not only the public domain but the public psyche too.
The most startling example of this phenomenon is that of serotonin. Serotonin and its fluctuating ‘levels’ in the brain have been widely accepted as signifiers of depression. The debate has often been more about which comes first: the feelings of distress and depression or the changes in levels of serotonin. However, Davies from his reading of the research argues there is no firm evidence to place levels of serotonin as a conclusive marker of depression. What is clear though, is that it is in the interests of the pharmaceutical industry to foster a chemical explanation. In other words, we are back to the old battle of the biological versus the social, a battle that was waged by R.D. Laing and others on orthodox psychiatry, but which has subsequently appeared to be ultimately lost. What Davies reveals is that this battle is still on and the case for resisting biological approaches remains strong. However, this battle is not currently being waged in the wider public domain and might even be being deliberately suppressed.
In a recent conversation I had with Davies about the widespread public acceptance of biological explanations of emotional distress he had this to say:
“In writing the book my views changed greatly. When I started working as a therapist I took the line that many therapists take today which is this: in combination, therapy and drugs are the best way of proceeding. I now believe that view to be completely wrong. Medications get in the way of therapy! They undermine the work we are trying to do. If you believe that part and parcel of someone's recovery is encountering and working through difficult feelings and emotions. Well, medications that numb those emotions simply stop that process from unfolding. Another conflict we encounter is when working with clients who have been led to believe that their brain is in control here. Then how do you get those clients to begin to subscribe to the notion that they are more in control of their lives than they have been led to believe? This really is the prerequisite to get therapy to work; the assumption that therapy can work. Receiving a diagnosis can sometimes undermine that belief and lead to a fatalism in the client that whatever they do, however hard they work they are forever doomed to this biological misfortune.”
Davies, in bringing this information to the general reader, is helping patients and service users to make an informed choice. For several years now the NHS has been trumpeting its commitment to patient choice. There is little or no patient choice in mental health services. They operate on a strictly postcode basis. If there isn't a good service where you live tough! From a clinical perspective the aim of the book is to challenge the medicalisation of distress and in doing so to depathologise the patient's experience - a project I assume all readers of Sitegeist would sign up for. It is a call to arms from Davies and he is passionate about this. The case studies that illustrate some of the text are both moving and disturbing.
The final part of the book is about the economics of the pharmaceutical industry and their involvement at both institutional and individual level with the psychiatric fraternity. None of it is surprising but the extent is shocking and the amount of money is staggering. Perhaps it is this section of the book that could lay Davies open to accusations of conspiracy theory. I would challenge this and would say that he has been very careful to back up any claims with evidence. In examining what he calls ‘psychiatric imperialism’ or the spreading of diagnoses internationally he reveals how this opens up the market for ‘Big Pharma’.
It is also important to contextualise Cracked with other contemporary events, in particular one of which is recorded in the book and one that is not. Davies is writing about psychiatry and not about clinical psychology. Nevertheless, I think it should be noted that at the consultation stage of DSM-V the BPS (British Psychological Society) responded officially with grave concerns about the DSM's ever increasing number of disorders. In the book Davies records that there was to be an editorial in the British Journal of Psychiatry written by 29 eminent consultant psychiatrists expressing concern over the current state of psychiatry and how it is not working and advocates a more social and less biological approach. This runs counter to the view expressed in this journal which generally calls for more medication of ‘brain based’ mental diseases and more diagnoses as a way to resolve the current crisis. To find out more Davies interviews Professor Sue Bailey President of the Royal College of Psychiatrists and this is where he encounters the most hostility. His interview with her is quoted from extensively. Her responses are both aggressive and defensive. She partly has a point when she says that GPs are responsible for over prescribing of antidepressants but one of the major factors for this overprescribing is the PHQ9 (Patient Health Questionnaire 9) which was devised by Robert Spitzer and is copyrighted by Pfizer Inc., the Pharmaceutical giant. So over prescribing by GPs is ultimately on the advice from psychiatrists and they must take responsibility for this. Professor Bailey accuses her colleagues who are questioning the status quo of being zealots whilst claiming that she, and presumably she includes the rest of her colleagues, is being more eclectic! Whatever the truth of the matter Cracked has certainly exposed a crack! This challenge has now been published but not as an editorial, rather as a special article. What this change means is open to conjecture but to me it indicates a distancing by the Royal College of Psychiatrists from these views.
Fundamentally, this is a book written with humanity and genuine concern for the most vulnerable members of society and it makes it abundantly clear that increased numbers of diagnoses are reductive and do little to expand our understanding of suffering. I, personally, applaud a work that can shine a light into the murky corners of dubious practice. I would rather that light came from a theatrical spotlight to be seen by many than an academic candle that illuminates for the few.
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